Check out this fantastic review article about pyoderma gangrenosum (PG) by Dr. Alex Loayza and colleagues from the Oregon Health and Science University’s Department of Dermatology. Dr. Loayza has been incredibly generous with his time and expertise when wound care practitioners have needed help with cases of PG, and I am grateful for him for his academic and clinical expertise! PG is a neutrophilic dermatosis, the etiology of which remains unclear. It is often associated with underlying autoimmune diseases. I have seen many cases associated with rheumatoid arthritis, Chron’s and ulcerative colitis, as well as “bird fanciers’ disease. I have seen it as a paraneoplastic syndrome, and associated with genetic factors such as PASH (Pyoderma gangrenosum, Acne, and Suppurative Hidradenitis). PG may be triggered by surgery or trauma due to pathergy. Pathergy is the reason that any wound center patient who gets WORSE with debridement needs to be evaluated for PG. Although a biopsy is generally the right thing to do, a negative biopsy does not rule out PG. The best way to evaluate a patient is with the PARACELSUS tool.
While I am not a dermatologist, I am confident that, like most wound care practitioners, I have seen more cases of PG than all but a handful of dermatologists. Surprisingly, an academic dermatology practice failed to diagnose PG in the patient with PASH. In fact, they didn’t even diagnose the PASH, despite the patient’s multiple inflammatory conditions — but insisted that his leg lesions were vascular in origin despite the proven absence of arterial disease and the total absence of any symptom of venous disease. That explains why PG is still considered “rare,” when in fact, it was common for me to have 6 to 8 cases at a time in the wound center. PG is NOT rare — it is only rarely diagnosed. Cases of PG are more likely to be seen in wound centers than dermatology practices. The US Wound Registry (USWR), comprised of the aggregated patient records from more than 500 wound practitioners, contains hundreds of diagnosed cases of PG. This is confirmation that the disease is not rare.
Clinicians often email me about how a particular dressing or “skin substitute” worked miracles in a case of PG, but a Band-Aid will appear to have miraculous healing power once the inflammatory condition is suppressed. Once suppressed, the lesions heal themselves. Unfortunately, getting the inflammatory state suppressed almost always requires systemic medication, although occasionally small, isolated lesions can be treated with an injection of Kenalog. Dr. Loayza’s review article is a wonderful synthesis of the current understanding of PG’s complex pathogenesis. Understanding the possible immune pathways may guide treatment and future drug development. The article will certainly help wound care practitioners, as they continue to be the tip of the spear in the diagnosis and treatment of PG.
More Resources:
- Download my presentation about PARACELSUS
- Case reports:
- Find all my blog posts about PG here with photos of cases
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
